registration form

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2017-18 MOPS International

REGISTRATION FORM

YOUR CONTACT INFO

WELCOME! PLEASE COMPLETE THIS FORM SO WE CAN LEARN ABOUT YOU!

Last Name: _________________________________________ First Name: ____________________________________ M.I.: ______ Home Phone: __________________________________________

Alternate Phone: __________________________________________________

Address: ______________________________________________________________________________________________________________________________

City: __________________________________________________________________ State: _________ Zip Code: _______________________

Email: ___________________________________________________________________ Birthday: _________________________________

YOUR MOPS INFO

Name of MOPS Group: ______________________________________________________________________________________ Have you attended a MOPS group before?

Yes

No If yes, where?

Are you already registered for the MOPS International Membership?

_____________________________________________ Yes

No

Home church (if applicable): _________________________________________________________________________________ How did you hear about this MOPS group? _____________________________________________________________________

YOUR FAMILY INFO

Please list your child(ren)’s name(s) and birthdate(s): Name: ____________________________________________________________________________________________________ Date of Birth: _____________________________________________________________________________________________ Name: ____________________________________________________________________________________________________ Date of Birth: _____________________________________________________________________________________________ Name: ____________________________________________________________________________________________________ Date of Birth: ______________________________________________________________________________________________ Husband’s Name (if applicable): ______________________________________________________________________________

MOPS Membership Fee .............................................................................................................................................................................. Please make checks payable to Covenant Church and drop off in the church office or mail to: Covenant Church, 4000 Route 202, Doylestown, PA 18902 (Financial Assistance/Payment Plans are available based on need. Please contact Kim in the church office at: 267-880-3713)

MOPS Meeting Time: 9:15 – 11:00 AM

MOPS Meeting Dates: October 5th, November 2nd, December 7th January 4th, February 1st, March 1st, April 5th, May 3rd * For Group Use Only

Payment in Full/Payment Plan:_____________________________________________________________________________ Date Registration Discussion Group

Received: _____________________________________________________________________________ Assigned: _____________________________________________________________________________

Date Registered for MOPS International Membership: _________________________________________________

$72.00